42 USC 1396u-5 - Special provisions relating to medicare prescription drug benefit

U.S Code last checked for updates: Nov 22, 2024

§ 1396u–5.

Special provisions relating to medicare prescription drug benefit

(a)

Requirements relating to medicare prescription drug low-income subsidies, medicare transitional prescription drug assistance, and medicare cost-sharing

As a condition of its State plan under this subchapter under section 1396a(a)(66) of this title and receipt of any Federal financial assistance under section 1396b(a) of this title subject to subsection (e), a State shall do the following:

(1)

Information for transitional prescription drug assistance verification

(2)

Eligibility determinations for low-income subsidies

The State shall—

(A)

make determinations of eligibility for premium and cost-sharing subsidies under and in accordance with section 1395w–114 of this title;

(B)

inform the Secretary of such determinations in cases in which such eligibility is established; and

(C)

otherwise provide the Secretary with such information as may be required to carry out part D, other than subpart 4, of subchapter XVIII (including section 1395w–114 of this title).

(3)

Screening for eligibility, and enrollment of, beneficiaries for medicare cost-sharing

(4)

Consideration of data transmitted by the Social Security Administration for purposes of Medicare Savings Program

(b)

Regular Federal subsidy of administrative costs

(c)

Federal assumption of medicaid prescription drug costs for dually eligible individuals

(1)

Phased-down State contribution

(A)

In general

Each of the 50 States and the District of Columbia for each month beginning with January 2006 shall provide for payment under this subsection to the Secretary of the product of—

(i)

the amount computed under paragraph (2)(A) for the State and month;

(ii)

the total number of full-benefit dual eligible individuals (as defined in paragraph (6)) for such State and month; and

(iii)

the factor for the month specified in paragraph (5).

(B)

Form and manner of payment

(C)

Compliance

(D)

Data match

(2)

Amount

(A)

In general

The amount computed under this paragraph for a State described in paragraph (1) and for a month in a year is equal to—

(i)

¹⁄₁₂ of the product of—

(I)

the base year State medicaid per capita expenditures for covered part D drugs for full-benefit dual eligible individuals (as computed under paragraph (3)); and

(II)

a proportion equal to 100 percent minus the Federal medical assistance percentage (as defined in section 1396d(b) of this title) applicable to the State for the fiscal year in which the month occurs; and

(ii)

increased for each year (beginning with 2004 up to and including the year involved) by the applicable growth factor specified in paragraph (4) for that year.

(B)

Notice

(3)

Base year state medicaid per capita expenditures for covered part D drugs for full-benefit dual eligible individuals

(A)

In general

For purposes of paragraph (2)(A), the “base year State medicaid per capita expenditures for covered part D drugs for full-benefit dual eligible individuals” for a State is equal to the weighted average (as weighted under subparagraph (C)) of—

(i)

the gross per capita medicaid expenditures for prescription drugs for 2003, determined under subparagraph (B); and

(ii)

the estimated actuarial value of prescription drug benefits provided under a capitated managed care plan per full-benefit dual eligible individual for 2003, as determined using such data as the Secretary determines appropriate.

(B)

Gross per capita medicaid expenditures for prescription drugs

(i)

In general

(ii)

Determination

In determining the amount under clause (i), the Secretary shall—

(I)

use data from the Medicaid Statistical Information System (MSIS) and other available data;

(II)

exclude expenditures attributable to covered outpatient prescription drugs that are not covered part D drugs (as defined in section 1395w–102(e) of this title, including drugs described in subparagraph (K) of section 1396r–8(d)(2) of this title); and

(III)

reduce such expenditures by the product of such portion and the adjustment factor (described in clause (iii)).

(iii)

Adjustment factor

The adjustment factor described in this clause for a State is equal to the ratio for the State for 2003 of—

(I)

aggregate payments under agreements under section 1396r–8 of this title; to

(II)

the gross expenditures under this subchapter for covered outpatient drugs referred to in clause (i).

Such factor shall be determined based on information reported by the State in the medicaid financial management reports (form CMS–64) for the 4 quarters of calendar year 2003 and such other data as the Secretary may require.

(C)

Weighted average

The weighted average under subparagraph (A) shall be determined taking into account—

(i)

with respect to subparagraph (A)(i), the average number of full-benefit dual eligible individuals in 2003 who are not described in clause (ii); and

(ii)

with respect to subparagraph (A)(ii), the average number of full-benefit dual eligible individuals in such year who received in 2003 medical assistance for covered outpatient drugs through a medicaid managed care plan.

(4)

Applicable growth factor

The applicable growth factor under this paragraph for—

(A)

each of 2004, 2005, and 2006, is the average annual percent change (to that year from the previous year) of the per capita amount of prescription drug expenditures (as determined based on the most recent National Health Expenditure projections for the years involved); and

(B)

a succeeding year, is the annual percentage increase specified in section 1395w–102(b)(6) of this title for the year.

(5)

Factor

The factor under this paragraph for a month—

(A)

in 2006 is 90 percent;

(B)

in 2007 is 88⅓ percent;

(C)

in 2008 is 86⅔ percent;

(D)

in 2009 is 85 percent;

(E)

in 2010 is 83⅓ percent;

(F)

in 2011 is 81⅔ percent;

(G)

in 2012 is 80 percent;

(H)

in 2013 is 78⅓ percent;

(I)

in 2014 is 76⅔ percent; or

(J)

after December 2014, is 75 percent.

(6)

Full-benefit dual eligible individual defined

(A)

In general

For purposes of this section, the term “full-benefit dual eligible individual” means for a State for a month an individual who—

(i)

has coverage for the month for covered part D drugs under a prescription drug plan under part D of subchapter XVIII, or under an MA–PD plan under part C of such subchapter; and

(ii)

is determined eligible by the State for medical assistance for full benefits under this subchapter for such month under section 1396a(a)(10)(A) or 1396a(a)(10)(C) of this title, by reason of section 1396a(f) of this title, or under any other category of eligibility for medical assistance for full benefits under this subchapter, as determined by the Secretary.

(B)

Treatment of medically needy and other individuals required to spend down

(d)

Coordination of prescription drug benefits

(1)

Medicare as primary payor

(2)

Coverage of certain excludable drugs

(e)

Treatment of territories

(1)

In general

In the case of a State, other than the 50 States and the District of Columbia—

(A)

the previous provisions of this section shall not apply to residents of such State; and

(B)

subject to paragraph (4), if the State establishes and submits to the Secretary a plan described in paragraph (2) (for providing medical assistance with respect to the provision of prescription drugs to part D eligible individuals), the amount otherwise determined under section 1308(f) of this title (as increased under section 1308(g) of this title) for the State shall be increased by the amount for the fiscal period specified in paragraph (3).

(2)

Plan

The Secretary shall determine that a plan is described in this paragraph if the plan—

(A)

provides medical assistance with respect to the provision of covered part D drugs (as defined in section 1395w–102(e) of this title) to low-income part D eligible individuals;

(B)

provides assurances that additional amounts received by the State that are attributable to the operation of this subsection shall be used only for such assistance and related administrative expenses and that no more than 10 percent of the amount specified in paragraph (3)(A) for the State for any fiscal period shall be used for such administrative expenses; and

(C)

meets such other criteria as the Secretary may establish.

(3)

Increased amount

(A)

In general

The amount specified in this paragraph for a State for a year is equal to the product of—

(i)

the aggregate amount specified in subparagraph (B); and

(ii)

the ratio (as estimated by the Secretary) of—

(I)

the number of individuals who are entitled to benefits under part A ¹ or enrolled under part B ¹ and who reside in the State (as determined by the Secretary based on the most recent available data before the beginning of the year); to

(II)

the sum of such numbers for all States that submit a plan described in paragraph (2).

(B)

Aggregate amount

The aggregate amount specified in this subparagraph for—

(i)

the last 3 quarters of fiscal year 2006, is equal to $28,125,000;

(ii)

fiscal year 2007, is equal to $37,500,000; or

(iii)

a subsequent year, is equal to the aggregate amount specified in this subparagraph for the previous year increased by annual percentage increase specified in section 1395w–102(b)(6) of this title for the year involved.

(4)

Treatment of funding for certain fiscal years

(5)

Report

(Aug. 14, 1935, ch. 531, title XIX, § 1935, as added and amended Pub. L. 108–173, title I, § 103(a)(2)(B), (b)–(d)(1), Dec. 8, 2003, 117 Stat. 2154–2158; Pub. L. 109–91, title I, § 104(c), Oct. 20, 2005, 119 Stat. 2093; Pub. L. 110–275, title I, § 113(b), July 15, 2008, 122 Stat. 2506; Pub. L. 116–94, div. N, title I, § 202(b), Dec. 20, 2019, 133 Stat. 3107.)

cite as: 42 USC 1396u-5